Provider Demographics
NPI:1962900357
Name:KENNEDY, ANDRE JOHNATHAN (PA)
Entity type:Individual
Prefix:
First Name:ANDRE
Middle Name:JOHNATHAN
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:9735 KINCEY AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-9120
Mailing Address - Country:US
Mailing Address - Phone:704-414-2870
Mailing Address - Fax:
Practice Address - Street 1:111 W HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3405
Practice Address - Country:US
Practice Address - Phone:803-796-8515
Practice Address - Fax:803-796-8515
Is Sole Proprietor?:No
Enumeration Date:2018-01-31
Last Update Date:2021-05-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
SC2832363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2832OtherSOUTH CAROLINA DEPARTMENT OF LABOR, LICENSING AND REGULATION